Incidence, Predictors, and Outcomes of Symptomatic Intracranial Hemorrhage after Tenecteplase in Acute Ischemic Stroke

Abstract Background and Objectives: Symptomatic intracranial hemorrhage (SICH) after thrombolysis is a major safety concern in the management of acute ischemic stroke (AIS). This study evaluates the predictors and outcomes of SICH among AIS patients receiving tenecteplase. Methods: This multicenter retrospective observational study included AIS patients who received tenecteplase between December 2021 and June 2024 at 41 Swasthya Ingit Telestroke Network hospitals in West Bengal, India. Results: Of 1,463 tenecteplase-treated AIS patients, 68 (4.64%) developed SICH. Mixed-effects multivariable logistic regression showed that age >61 years (adjusted odds ratio aOR 2.37, 95% confidence interval CI 1.38–4.07), hyperlipidemia (aOR 2.84, 95% CI 1.28–6.31), atrial fibrillation (aOR 4.84, 95% CI 1.86–12.59), smoking (aOR 2.55, 95% CI 1.30–5.00), systolic blood pressure >150 mmHg on admission (aOR 2.09, 95% CI 1.25–3.48), and a baseline National Institutes of Health Stroke Scale (NIHSS) score >9 (aOR 1.71, 95% CI 1.03–2.86) were associated with higher odds of SICH. An Alberta Stroke Program Early CT Score (ASPECTS) <8 was an additional risk factor among patients with middle cerebral artery (MCA) territory infarcts (aOR 3.32, 95% CI 1.70–6.50). Among the 313 patients who underwent angiography, the presence of large vessel occlusion was also associated with increased odds of SICH (aOR 5.65, 95% CI 1.86–17.19). In the SICH group, significantly fewer patients achieved a favorable outcome (mRS 0–2) at 90 days (7.4% vs 60.6%, P < 0.001), and all-cause mortality was significantly higher (79.4% vs 12.3%, P < 0.001). Conclusions: SICH after tenecteplase use in AIS is associated with increased morbidity and mortality. Older age, higher baseline NIHSS scores, elevated systolic blood pressure on admission, smoking, hyperlipidemia, atrial fibrillation, lower ASPECTS, and large vessel occlusion are associated with a higher risk of SICH in tenecteplase-treated AIS patients.